Sutureless Pars Plana Anterior Vitrectomy Through Self-Sealing

CASE REPORTS AND SMALL CASE SERIES

(Figure 1). The mass was vividly platelets) and to 6000000 U/wk in Interferon alfa Therapy red and contained prominent inter- and after the third week. The iris tu- Against Metastatic Iris nal blood vessels. Satisfactory visu- mor began to regress about 3 weeks Tumor of Renal Cell alization of the entire right fundus after the beginning of interferon alfa was not possible because of insuffi- administration, and it appeared to- Carcinoma cient mydriasis, but a retinal detach- tally regressed and white after 16 ment was noted in the periphery be- weeks (Figure 1). The retinal de- Ocular metastasis of renal cell carci- tween the 3- and 7-o’clock positions. tachment disappeared, and the ul- noma is rare, and metastasis to the iris B-scan ultrasonography revealed a trasonographically demonstrated tu- or ciliary body is especially uncom- ciliary body mass at the inferonasal mor in the ciliary region was not mon. Ferry and Font1 studied 227 part of the ciliary body. No abnor- detected. However, the tumor me- cases of metastatic tumors of the eye mality was noted in the left eye. tastasized to the lung, liver, and and orbit and reported that 26 Systemic examination re- bones thereafter, and the patient died (11.5%) of these lesions were iris or vealed swelling of the cervical lymph on June 20, 1993. ciliary body tumors and that 2 (0.9%) nodes, and results of computed to- originated in the kidney. We exam- mographic scans and magnetic reso- Comment. Renal cell carcinoma ac- ined a patient with an iris tumor that nance images of the head disclosed counts for 80% to 85% of the ma- metastasized from a renal cell carci- a cerebral tumor in the right occipi- lignant tumors of the kidney.2 Me- noma and observed marked effects of tal lobe. Biopsy of the cervical lymph tastases were reported to be present interferon alfa administration. nodes established lymph node me- in 25% to 30% of patients with re- tastasis of the renal cell carcinoma nal cell carcinoma at the initial ex- Report of a Case. A 55-year-old man (Figure 2). Because neurological amination.2 Metastases of renal cell was seen on September 3, 1992, with symptoms such as disturbance of carcinoma are hematogenous and a 1-week history of decreased vi- consciousness appeared thereafter, lymphogenous, and the lungs are the sion in his right eye. His history in- the brain tumor was resected on Oc- most frequent site of the distant me- cluded radical right nephrectomy for tober 8, and the tumor was con- tastases, followed by metastases to renal cell carcinoma in December firmed histopathologically to be a bones, liver, and brain.2 Metastases 1990 and left partial pneumonec- metastasis of the renal cell carci- to the eye are rare, and those to the tomy due to lung metastasis in June noma. iris have been documented in only 1992. Systemic interferon alfa was a few cases, including those re- The corrected visual acuity was started on October 23 for conserva- ported by Ferry and Font1 and Wy- 20/20 OU and the intraocular pres- tive treatment of the iris tumor. The zinski et al.3 The iris tumor of our sure was 11 mm Hg OU. Slitlamp dose was set initially at 21000000 patient appeared vividly red through biomicroscopy showed cells in the U/wk, but it was reduced to the biomicroscope (Figure 1). This anterior chamber and a well- 9000000 U/wk in the second week color has been recognized by some circumscribed solid tumor (8 ϫ 4 due to bone marrow suppression clinicians as characteristic of many mm) in the iris of the right eye (decrease in white blood cells and metastatic ocular tumors from re-

Figure 1. Left, A well-circumscribed solid tumor, which appeared vividly red and contained prominent internal blood vessels, is observed on the iris between the 3- and 7-o’clock positions. Right, The tumor appeared to be totally regressed and white 16 weeks after the beginning of interferon alfa administration.

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©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 ists included number of years since completion of clinical training and complexity of the detachment.2 Complications of pneumatic retinopexy have been well described and involve the anterior and posterior segments.3,4 These include: cataract, choroidal detachment, delayed resorption or shifting of subretinal fluid, endophthalmi- tis, pars plana/subconjunctival/ subretinal gas, malignant glaucoma, peripheral subretinal hemorrhage, vitreous hemorrhage, iris incarceration, macular hole/pucker, neck pain, subretinal/vitreous pigment, prolif- erative vitreoretinopathy, refractive changes, untreated retinal breaks, Figure 2. Light microscopic appearance of lymph node metastasis displaying sheets of uveitis, vitreous incarceration/loss, polyhedral-shaped cells with clear cytoplasm (hematoxylin-eosin, original magnification ϫ100). and central retinal artery occlusion.3,4 Self-sealing, clear corneal inci- nal cell carcinoma. Our patient was Miyakojima-ku, Osaka 534-0021, sions for cataract extraction have be- treated conservatively because no re- Japan (e-mail: [email protected]). come increasingly popular recently duction of vision or secondary glau- owing to the combined advantages 1. Ferry AP, Font RL. Carcinoma metastatic to the coma due to the tumor was noted, eye and orbit, II: a clinicopathological study of of phacoemulsification, foldable in- and because the prognosis was poor 26 patients with carcinoma metastatic to the an- traocular lenses, and topical anes- due to multiple organ metastases. terior segment of the eye. Arch Ophthalmol. 1975; thesia.5 Wound strength was one of 93:472-482. Renal cell carcinoma resists rou- 2. Motzer RJ, Bander NH, Nanus DM. Renal-cell the early criticisms of this tech- tine chemotherapy and radiother- carcinoma. N Engl J Med. 1996;335:865-875. nique, although studies suggest that 2 3. Wyzinski P, Rootman J, Wood W. Simulta- apy. However, since interferon alfa neous bilateral iris metastases from renal cell car- the integrity of small incision, clear has recently been reported to have a cinoma. Am J Ophthalmol. 1981;92:206-209. corneal incisions is comparable with direct antiproliferative effect on re- 4. Nanus DM, Pfeffer LM, Bander NH, Bahri S, Al- traditional limbal or scleral based in- 4 bino AP. Antiproliferative and antitumor ef- 5 nal tumor cells in vitro, and to stimu- fects of alpha-interferon in renal cell carcino- cisions. Typically, self-sealing clear late host mononuclear cells and mas: correlation with the expression of a kidney- corneal incisions are reinforced via enhance the expression of major- associated differentiation glycoprotein. Cancer stromal hydration at the end of the Res. 1990;50:4190-4194. histocompatibility-complex mol- procedure, and sutures can be used ecules,2 it has been introduced as a to enhance wound integrity. new treatment for renal cell carci- The 2 cases in which clear cor- noma. More recently, the effects of neal incisions from recent cataract interferon alfa when used in combi- Clear Corneal Cataract surgery dehisced during pneu- nation with interleukin 2 and fluo- Wound Dehiscence During matic retinopexy. To our knowl- rouracil, or with 13-cis-retinoic acid, Pneumatic Retinopexy edge, this potentially dangerous have been evaluated.2 The response complication of pneumatic retino- rate of patients to interferon alfa alone Pneumatic retinopexy is generally pexy has not been reported previ- is considered to be about 20%, and accepted as a safe and effective treat- ously. However, it may become in- its therapeutic effect is limited when ment for certain types of retinal de- creasingly common given the it is used alone. However, as some pa- tachment. This procedure recently growing popularity of clear corneal tients such as ours show marked has been demonstrated to produce cataract extraction and the in- responses, interferon alfa may be use- equivalent final visual outcomes and creased risk of retinal detachment ful in patients with intraocular me- reattachment rates compared with imparted by intraocular surgery and tastases of renal cell carcinoma. scleral buckling for primary rheg- pseudophakia. matogenous retinal detachment.1 Tomohiro Ikeda, MD The growing popularity of this tech- Report of Cases. Case 1. A 49-year- Keiko Sato, MD nique was verified in a recent sur- old white man underwent clear cor- Takanobu Tokuyama, MD vey of members of the Retina and nea cataract extraction and poste- Osaka, Japan Vitreous Societies that revealed that rior chamber intraocular lens pneumatic retinopexy is the treat- implantation in the left eye on June Corresponding author: Tomohiro ment of choice for “uncompli- 11, 1999. The procedure was com- Ikeda, MD, Department of Ophthal- cated” retinal detachments.2 Fac- plicated by a small tear in the pos- mology, Osaka City General Hospi- tors influencing the selection of this terior lens capsule at the 4-o’clock tal, 2-13-22, Miyakojimahondori, modality by vitreoretinal special- position, which did not require an-

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©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 terior vitrectomy. The corneal sentially normal posterior segment in tesis may be performed prior to gas wound was closed with a single 10-0 the left eye. On August 19,1998, fol- injection to minimize a rapid in- polyglactin (Vicryl) suture, and the low-up examination revealed a small, crease in IOP. Alternatively, smaller wound was watertight at the con- rhegmatogenous retinal detach- volumes of injected gas may be used clusion of the operation. The post- ment superonasally in the left eye for pneumatic retinopexy per- operative course was uneventful un- arising from a retinal break at a pre- formed in the setting of recent clear til June 23, 1999, when the patient vious sclerotomy site. Cryopexy was corneal cataract extraction. was diagnosed with a single retinal applied to the breaks, and pneu- break at the 12:30-o’clock position matic retinopexy was attempted us- Albert S. Jun, MD, PhD and a macula-on, rhegmatogenous ing 0.3 cc of 100% sulfahexafluo- Dante J. Pieramici, MD retinal detachment in the left eye su- ride. During the gas injection, the Baltimore, Md perotemporally. Intraocular pressure clear corneal wound dehisced, and William Z. Bridges, Jr, MD (IOP) was noted to be 15 mm Hg. aqueous fluid was ejected forcibly Asheville, NC Topical and subconjunctival anes- enough to impact the surgeon’s face thesia were administered, and cryo- at a distance of approximately 2 ft Corresponding author: Dante J. pexy was applied to the breaks. The (60.9 cm). No prolapse of ocular struc- Pieramici, MD, Maumenee 215, 10-0 polyglactin suture placed at the tures occurred, and the dehisced Wilmer Ophthalmological Institute, conclusion of the cataract extrac- wound was allowed to self-seal with- The Johns Hopkins Medical Institu- tion was absent from the clear cor- outsutures.ThepostoperativeIOPwas tions, 600 N Wolfe St, Baltimore, MD neal wound. Pneumatic retinopexy 16 mm Hg. On September 4, 1998, the 21287-9277 (e-mail: dpieramici then was performed using 0.5 cc of persistent retinal detachment was re- @jhmi.edu.). 100% sulfahexafluoride injected attached successfully via pars plana vi- through the pars plana. During the trectomy, cryopexy, scleral buckling, 1. Han DP, Mohsin NC, Guse CE, Hartz A, Tarka- gas injection, the clear corneal fluid gas exchange, and endolaser nian CS. Comparison of pneumatic retinopexy and scleral buckling in the management of pri- wound deshisced with iris pro- treatment. mary rhegmatogenous retinal detachment. Am lapse. A paracentesis then was per- J Ophthalmol. 1999;126:658-668. 2. Benson WE, Chan P, Sharma S, Snyder WB, formed to allow further decompres- Comment. We reported 2 cases of Bloome MA, Birch DG. Current popularity of sion of the eye. Viscoelastic was used a previously unreported compli- pneumatic retinopexy. Retina. 1999;19:238- to re-form the anterior chamber, and cation of pneumatic retinopexy 241. 3. Hilton GF, Tornambe PE, The Retinal Detach- prolapsed iris was reposited via the causing dehiscence of clear corneal ment Study Group. Pneumatic retinopexy: an wound. Subsequently, the clear cor- incisions from recent cataract ex- analysis of intraoperative and postoperative com- neal wound was found to be sealed tractions. Despite the potential se- plications. Retina. 1991;11:285-294. 4. Abe T, Nakajima A, Nakamura H, Ishikawa M, without sutures, and the postopera- riousness of this complication, these Sakuragi S. Intraocular pressure during pneu- tive IOP was 15 mm Hg. The retina cases resolved without incident. matic retinopexy. Ophthalmic Surg Lasers. 1998; 29:391-396. reattached completely following the Among the previously described 5. Fine IH, ed. Clear Corneal Lens Surgery. Thoro- procedure, and the gas was re- complications of pneumatic retino- fare, NJ: SLACK Inc; 1999. sorbed by 3 weeks postoperatively. pexy, central retinal artery occlu- However, 1 month postoperatively sion also results from high IOPs cre- a new inferotemporal retinal tear and ated during this procedure.4 As detachment developed in the left eye suggested by Abe et al,4 such com- Bilateral Scleral Thermal that were treated successfully on July plications could be minimized via Injury: Complication After 27, 1999, via cryopexy and scleral routine IOP monitoring and para- Skin Laser Resurfacing buckling. centesis during pneumatic retino- Case 2. An 81-year-old white pexy. In 1980, Beckmann and Fuller1 were man underwent clear corneal cata- Both cases demonstrated the first to use the carbon dioxide ract extraction in the left eye on July wound dehiscence less than 3 weeks (CO2) laser in blepharoplastic sur- 31, 1998, complicated by posterior after cataract surgery. More cases of gery. Reported advantages of CO2 dislocation of the lens nucleus. An in- this complication will be required laser blepharoplasty include de- traocular lens was inserted, and the before a reliable estimate can be creased postoperative edema, less clear corneal wound was closed with- made of the length of time suffi- pain, and a shorter convalescence in out sutures. On postoperative day 1, cient for such wounds to become comparison with conventional sur- increased intraocular inflammation fully stable for pneumatic retino- gery.2 We are aware of only 1 re- and an IOP of 45 mm Hg prompted pexy. Given the increasing popular- port on the use of a combined CO2/ pars plana vitrectomy and lensec- ity of clear corneal cataract extrac- Nd:YAG laser: in 1996, Katalinich3 tomy. Intraoperatively, a small reti- tion and the elevated risk of retinal reported that 50 patients treated for nal tear was noted inferonasally, and detachment imparted by cataract ex- cutaneous neurofibromas had cryopexy was applied. No sutures traction and intraocular lens implan- shorter surgery times, less hemor- were placed to secure the clear cor- tation, this complication may be ob- rhages, and sufficient removal with neal wound as part of the secondary served with greater frequency in the the Nd:YAG laser vs with the CO2 vitreoretinal procedure. On postop- future. To reduce the potential for laser alone. To the best of our knowl- erative day 1 of the vitreoretinal pro- clear corneal wound dehiscence dur- edge, complications of this treat- cedure, examination revealed an es- ing pneumatic retinopexy, paracen- ment have not yet been described.

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©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 Report of a Case. A 45-year-old man sion in the left eye. Best-corrected vi- plained the transient visual acuity with Recklinghausen neurofibroma- sual acuity was 1.0 OD and 0.16 OS. loss. In kinetic perimetry, a relative tosis had undergone laser resurfac- In both eyes, left worse than right, defect to the right side was ob- ing because of multiple facial slitlamp microscopy revealed broad- served. Systemic and neurological in- neurofibromas, especially in the peri- based defects of the lower eyelid mar- flammatory diseases were excluded orbital region. He was treated in a gins (small arrows) with correspond- by clinical and laboratory investiga- plastic surgeon’s office using, as far ing conjunctiva-covered scleral tion and magnetic resonance imag- as we know, a combined CO2/Nd: lesions (large arrows), resembling a ing. Visual acuity recovered with YAG laser (Combolaser; Madtec thermal injury (Figure). The left eye high-dose systemic corticosteroids, GmbH, Ulm, Germany) (power set- showed slight intraocular inflamma- beginning with 100 mg of fluocorto- tings: CO2 laser, 20-25 watts [W]; tion. No injury of other anterior seg- lone daily and tapering off over 6 Nd:YAG laser, 7-8 W). The tech- ment structures was observed in ei- weeks. Seven months after the laser nique has been described by Katalin- ther eye. Intraocular pressure was 12 injury, visual acuity was 1.0 OU. Slit- ich3: the skin over the tumor is dis- mm Hg OU. The swinging flash- lamp microscopy revealed scarred sected, then the tumor is evaporated light test showed no afferent pupil- scleral lesions in correspondance with by a defocussed laser beam. The use lary defect. Funduscopy was nor- scarred lower eyelid margin defects of 2 laser types is supposed to re- mal in the right eye; in the left eye, it in both eyes. Macula and optic nerve move the neurofibromas radically revealed discrete optic nerve head head were normal in both eyes. A sec- enough.3 Five days after treatment, swelling, with peripapillary bleed- ond fluorescence angiogram was re- the patient was referred to our hos- ing and angiographically proven peri- fused by the patient. pital suffering from deteriorated vi- papillary exudation, which ex- Comment. In a safety study, plastic and metal corneal eye protectors were tested with CO2 laser beams of different energy levels to assess flam- mability and heat production: only the metal protectors showed no damage.4 Therefore, metal scleral eye protectors are recommended for laser treatment in the periorbital region.2 Although the plastic surgeon insists that he took adequate mea- sures to protect the globe, some doubts remain about whether these recommendations were considered properly in the case of this patient. To find out which laser source had caused which type of damage, we used a Monte-Carlo calculation (S. William, PhD, A. Terenji, PhD, unpublished data, December 1998) to estimate the laser intensity Left eye of a 45-year-old patient with conjunctiva-covered lesions (large arrows) corresponding to lower (watts per square centimeter) in dif- eyelid margin defects (smaller arrows). ferent tissues of the human eye when

Characteristics of Nd:YAG and Co2 Lasers in Eye Tissue*

Absorption Scatter Approximate Tissue Laser Coefficient,† Coefficient,‡ Factor of Penetration Total

Tissue Type Thickness, mm (Wavelength) µa (1/mm) µa (1/mm) Anisotropy§ Depth,ሻ mm Absorption, % Sclera 0.7 Nd:YAG (1.06 µm) 0.02 42.0 0.9 2.1 4.3

CO2 (10.6 µm) 83.2¶ 0.0 0.0 0.01 100.0 Vitreous 24.0 Nd:YAG 0.04¶ 0.001 0.0 27.8 38.0 Retina 0.2 Nd:YAG 0.3 26.0 0.96 0.8 1.6 Choroid 0.25 Nd:YAG 0.02 50.0 0.87 1.8 0.1

*CO2 indicates carbon dioxide. †Absorbed proportion of laser energy in 1 mm of tissue. ‡Scattered proportion of laser energy in 1 mm of tissue. §Direction of scattered beams: a factor of +1 indicates no scattering, all beams are directed in forward direction; 0, scattering ideally spheric in all directions; and −1, all beams are directed in backward direction. ࿣Distance covered by a photon until its energy has fallen down to 1/e (approximately 73%). ¶Coefficients of water.

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©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 2 either a CO2 or a Nd:YAG laser is lead to irreversible amblyopia. La- of the sclerotomy sites required su- employed (Table). This calcula- ser capsulotomy is not always pos- turing. No intraoperative or post- tion shows that nearly all the en- sible for pediatric patients and sur- operative complication was encoun- ergy of the CO2 laser is absorbed in gical removal is often necessary. The tered. the sclera, whereas the energy of the thickened membrane can be ap- Nd:YAG laser easily penetrates the proached anteriorly through the lim- Comment. Although the scleral ri- sclera and is able to damage the pos- bus or posteriorly through the pars gidity in children is lower, the self- terior pole. We therefore conclude plana. A limbal approach can ren- sealing effect of this technique was that the scleral lesions in our pa- der the intraocular lens unstable and good with the integrity of the eye- tient were most probably caused by the pars plana approach is usually balls well maintained. Sudden aCO2 laser, whereas the posterior more difficult owing to the lower changes in intraocular pressure pole damage in the left eye must have scleral rigidity in children.3 It is more during operation are reduced, mini- been caused by a Nd:YAG laser. Pen- common for the eyeball to collapse mizing complications like intraop- etrations of the globe after CO2 la- with leakage through the wounds in- erative hemorrhage, vitreous her- ser treatment have been reported traoperatively. Sutureless pars plana niations, and others. Suture-re- anecdotally but have not been pub- vitrectomy through self-sealing scle- lated problems, such as loosening, lished so far (J. J. Woog, written rotomies has been successfully per- exposure, and infections, are also communication, June 29, 1998). formed in adults.4 This study aimed avoided. This would have been more In conclusion, severe ocular at evaluating prospectively the safety difficult to manage in children where complications caused by CO2 or Nd: and efficacy of sutureless pars plana extra sessions under general anes- Yag laser treatment can occur if eye anterior vitrectomy through self- thesia may become necessary. The protection is inappropriate. There- sealing sclerotomies in children with exposure for surgery in younger chil- fore, safety considerations should be thick posterior pseudophakic mem- dren could be suboptimal; scleral observed carefully. brane. tunnels were created without diffi- culty 4.5 mm posterior to the lim- Helga Spelsberg, MD Report of a Case. A total of 8 eyes bus in our cases. This can be fur- Peter Hering, PhD in 5 children were recruited from the ther optimized by the modified Thomas Reinhard, MD Prince of Wales Hospital, Hong technique described by Chen6 and Rainer Sundmacher, MD, FRCOphth Kong, China, from March 1, 1998, Kwok et al7 for eyes with small pal- Du¨sseldorf, Germany to December 31, 1998. The chil- pebral fissures. The sutureless scle- dren’s mean age was 22 months (age rotomy approach appears to be safe Corresponding author: Helga Spels- range, 8-48 months) and the fol- and effective and with its addi- berg, MD, Eye Hospital, Heinrich- low-up time ranged from 3 to 12 tional values in pediatric patients, it Heine-University, Moorenstrasse 5, months (mean follow-up, 9 can be considered in selected cases. 40225 Du¨sseldorf, Germany (e-mail: months). All patients had congeni- [email protected]). tal cataract with cataract extraction Dennis S. C. Lam, FRCS, FRCOphth performed by phaco-assisted aspi- John K. H. Chua, MBBS, FRCS 1. Beckman H, Fuller TA. Carbon dioxide laser ration. Primary posterior chamber Alfred T. S. Leung, FRCS, FRCOphth scleral dissection and filtering procedure for glaucoma. Am J Ophthalmol. 1979;88:73-77. intraocular lens was inserted with Dorothy S. P. Fan, MBChB, FRCS 2. Goldbaum AM, Woog JJ. The CO2 laser in ocu- subsequent thickening of the pos- Joan S. K. Ng, MBChB, FRCS loplastic surgery. Surv Ophthalmol. 1997;42:255- Hong Kong, China 267. terior capsule along the visual axis 3. Katalinich D. Laser surgical treatment of neu- deemed necessary for surgical re- Srinivas K. Rao, MD rofibromas [in Russian]. Khirurgiia (Mosk). 1996; moval. A 2-port pars plana ap- Chennai, India 5:52-54. 4. Rohrich RJ, Gyimesi IM, Clark P, Burns AJ. CO2 proach was adopted as illumina- laser safety considerations in facial skin resur- tion was adequate from the operating This study was supported in part by facing. Plast Reconstr Surg. 1997;100:1285- microscope. Self-sealing scleroto- 1290. the Mr W. K. Lee Eye Foundation, mies were constructed in the same 4 Hong Kong, China. fashion as those described by Chen. Corresponding author: Dennis S. Only the 2 superior sclerotomies C. Lam, FRCS, RECOphth, , Depart- were necessary, one for irrigation Sutureless Pars Plana ment of Ophthalmology and Visual and the other for the vitreous cut- Sciences, The Chinese University of Anterior Vitrectomy ter, avoiding the inferior scle- Through Self-sealing Hong Kong, Hong Kong Eye Hospi- rotomy that was often the main tal, 147K, Argyle St, Kowloon, Hong Sclerotomies in Children source of leakage as reported by 5 Kong,China (e-mail: dennislam Milibak and Suveges. Scleral tun- @cuhk.edu.hk). Intraocular lens implantation in chil- nels of 2 mm long were created 3.5 dren has become increasingly com- to 4.5 mm posterior to the limbus 1. Cavallaro BE, Madigan WP, O’Hara MA, Kra- mer KK, Bauman WC. Posterior chamber intra- mon after cataract surgery with en- and the actual sclerotomy sites were ocular lens use in children. J Pediatr Ophthal- 1 couraging visual results. However, 1.5 to 2.5 mm from the limbus de- mol S trabismus. 1998;35:254-267. thickening of the posterior capsule pending on the age of the patient. 2. Pearson RV, Aylward GW, Marsh RJ. Outcome lensectomy: results and complications. Br J Oph- along the visual axis remains a com- The integrity of the wound closure thalmol. 1991;75:482-486. mon and major problem that can was tested by inspection and none 3. Quinn GE, Young TL. Retina and vitreous. In:

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©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 Isenberg SJ, ed: The Eye in Infancy. St Louis, Mo: Mosby-Year Book Inc; 1994:407. 4. Chen JC. Sutureless pars plana vitrectomy through self-sealing sclerotomies. Arch Ophthal- mol. 1996;114:1273-1275. 5. Milibak T, Suveges I. Complications of sutureless pars plana vitrectomy through self-sealing sclerotomies. Arch Ophthalmol. 1998;116:119. 6. Chen JC. Complications of sutureless pars plana vitrectomy through self-sealing sclerotomies. Arch Ophthalmol. 1998;116:119. 7. Kwok AKH, Tham CCY, Lam DSC, Li M, Chen JC. Modified sutureless sclerotomies in pars plana vitrectomy. Am J Ophthalmol. 1999;127:731- 733.

Retinal Artery Occlusion Following Coil Embolization of Carotid-Ophthalmic Aneurysms Figure 1. Fundus photograph of the right eye 2 weeks after central retinal artery occlusion and after coil embolization of the paraclinoid aneurysm. Note the diffuse macular edema and the irregular attenuated Paraclinoid aneurysms, such as ca- appearance of the arterioles due to hypoperfusion of the retina. The classic cherry-red spot seen in the rotid-ophthalmic aneurysms, repre- acute phase of central retinal artery occlusion has evolved to formation of hard exudates and intraretinal sent 5% of all intracranial aneu- and subretinal hemorrhage in the macula at this time. rysms. In the past, treatment involved surgical clipping of the aneurysm, coils and the heparin was reversed. A mm in diameter with a wide neck which is associated with 4% morbid- few hours after the procedure, the pa- (Figure 2). The patient had no fo- ity and 1% mortality even in elective tient complained of blurred vision in cal neurological deficits at the time, cases.1 A nonsurgical alternative treat- his right eye. Visual acuity was ini- and the aneurysm was embolized ment for intracranial aneurysms was tially 20/20 OU, and the fundi showed with Guglielmi detachable coils. The developed in 1990 that utilizes de- no signs of ischemia. Confrontation aneurysm was 95% occluded, but tachable coils placed by an endovas- testing showed constriction of the there was some coil protrusion into cular route to embolize the aneu- right visual field. Eight hours later, vi- the parent artery. Anticoagulation rysm and induce thrombus formation sual acuity deteriorated to hand mo- with intravenous heparin was admin- within the aneurysmal sac. The pro- tions OD and a relative afferent pu- istered for 48 hours in hopes of pre- cedure has the advantage of avoid- pillary defect was noted. Fundus venting thrombus formation. Shortly ing the risks of neurosurgery and en- examination revealed a central reti- after discontinuation of heparin abling treatment of aneurysms that are nal artery occlusion in the right eye therapy, the patient complained of 2 unclippable or otherwise associated (Figure 1). Cerebral angiography episodes of inferior visual field loss with a high morbidity. However, ce- showed that the coils were in satis- in the right eye. Visual acuity was rebral embolization can complicate factory position occluding the aneu- 20/20 OU, but confrontation visual this procedure.2,3 We report 2 cases rysm and that the right ophthalmic ar- field testing demonstrated an infero- of retinal artery occlusion following tery was patent. Because of perforation nasal field defect in the right eye. No coil embolization of nonruptured ca- of the aneurysm and the potential risk relative afferent pupillary defect was rotid-ophthalmic aneurysms. of disturbing the coils while trying to noted. Fundus examination showed catheterize the ophthalmic artery, whitening of the retina along the su- Report of Cases. Case 1. A 54-year- thrombolytic therapy was contrain- perotemporal arcade with sparing of old man had a subarachnoid hemor- dicated and intravenous heparin was the fovea consistent with a branch rhage on November 1996 secondary given instead. Topical timolol and in- retinal artery occlusion (Figure 3). to rupture of a left carotid-ophthal- travenous acetozolamide were ad- Angiography was performed to de- mic aneurysm that was successfully ministered, an anterior chamber tap termine if thrombus was present in embolized with coils. He also had a was performed, and the eye was mas- the carotid artery, but none was small right carotid-ophthalmic aneu- saged, but there was no visual recov- found. The position of the coils re- rysm measuring 4 mm in diameter ery. His visual acuity remained hand mained unchanged. The patient was that was intact and not treated. The motions OD in the remaining tem- again given anticoagulation therapy patient had full recovery and demon- poral field 4 months later. with intravenous heparin. Because of strated no neurological deficits. In Case 2. A 13-year-old girl with the presence of an incompletely oc- January 1999, he underwent coil em- tuberous sclerosis was found to have cluded aneurysm, coil protrusion, bolization of the right paraclinoid an- an intracranial aneurysm of the right and an embolic episode, she under- eurysm. While heparinized, there was carotid artery on magnetic reso- went surgical removal of the coil and perforation of the dome of the aneu- nance imaging. Angiography showed clipping of the aneurysm 4 days af- rysm during the procedure. The an- that the aneurysm was located in the ter the initial procedure. Visual acu- eurysm was completely packed with ophthalmic branch and measured 8.6 ity remained 20/20 OD postopera-

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©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 cause has been considered to be im- proper placement of clips on the ophthalmic artery, direct trauma to the nerve, or ischemia from vasospasm.4 Retinal artery occlusion, either branch or central, can be a devastating complication. Ophthalmologists and in- terventional neuroradiologists should be aware of this complication so that prompt treatment may be given. How- ever, in the context of a recently coiled paraclinoid aneurysm associated with subarachnoid hemorrhage, we con- sider fibrinolysis too risky and we only administer anticoagulation therapy to the patient. In elective cases, it is pru- dent to perform an ophthalmic examination with perimetery prior to treatment.

Bienvenido Castillo, Jr, MD Figure 2. Left, Angiogram of the right internal carotid artery showing an 8.6-mm carotid-ophthalmic Felipe De Alba, MD aneurysm (arrowheads) with a wide neck. Right, After coil embolization, the aneurysm is 95% occluded, John Thornton, FRCSI but some coil protrusion into the parent artery is noted. The ophthalmic artery is seen immediately proximal to the aneurysm (arrows) and remains patent on the postembolization angiogram. Gerard DeBrun, MD Jose Pulido, MD Chicago, Ill

Supported in part by an unrestricted grant from Research to Prevent Blind- ness Inc, New York, NY, and a core grant from the National Eye Insti- tute, Bethesda, Md. Corresponding author: Jose S. Pulido, MD, Department of Ophthal- mology, University of Illinois at Chi- cago Eye Center, 1855 W Taylor St, Chicago, IL 60612.

1. King J, Berlin J, Flamm E. Morbidity and mortality from elective surgery for asymptomatic, un- ruptured, intracranial aneurysms: a meta- analysis. J Neurosurg. 1994;81:837-842. 2. Klotzsch C, Nahser H, Henkes H, Kuhne D, Ber- lit P. Detection of microemboli distal to cerebral aneurysms before and after therapeutic embolization. Am J Neuroradiol. 1998;19:1315- 1318. Figure 3. Fundus photograph of the right eye showing occlusion of the superotemporal retinal artery 3. Vinuela F, Duckwiler G, Mawad M. Guglielmi branch after coil embolization of the paraclinoid aneurysm shown in Figure 2. The fovea is spared from detachable coil embolization of acute intracra- ischemia, and the patient maintains 20/20 visual acuity. nial aneurysm: perioperative anatomical and clinical outcome in 403 patients. J Neurosurg. 1997;86:475-482. tively, and the inferonasal field defect the only ophthalmic embolic com- 4. Rizzo J. Visual loss after neurosurgical repair of persisted. plications of 71 paraclinoid carotid paraclinoid aneurysms. Ophthalmology. 1995; aneurysms that have been treated with 102:905-910. Comment. Cerebrovascular ische- detachable coils at our institution. In mia from embolism is a known com- both cases, the ophthalmic arteries plication of coil embolization of ce- were patent at angiography and the rebral aneurysms. In one large case retinal artery was too small to be vi- Mucosal Leishmaniasis series involving 403 patients, Vin- sualized. The microemboli that Presenting as Sinusitis and uela et al3 reported an incidence of caused the retinal artery occlusion Optic Neuropathy 2.5%. The complication of retinal presumably arose from the throm- artery occlusion following this pro- bus that formed around the coils in Leishmaniasis, caused by the dismor- cedure, however, has not yet been the aneurysm. Visual loss following phic protozoa Leishmania, is typi- reported in the literature to our surgical clipping of paraclinoid an- cally observed in patients as 1 of 3 knowledge. These 2 cases represent eurysms has been reported, but the clinical syndromes. Cutaneous leish-

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©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 maniasis with chronic nonhealing ul- cers that involve the face and ex- tremities is the most common manifestation. Mucosal leishmaniasis invades the nose, oral cavity, and pharynx. Visceral leishmaniasis is characterized by fever, wasting, hepa- tosplenomegaly, and pancytope- nia.1,2 To date, the only ocular problem has been eyelid involvement secondary to adjacent facial cutaneous infiltration.3,4 In view of the recent association between leishmaniasis and acquired immunodeficiency syndrome (AIDS),5 additional ophthalmological manifestations may be anticipated. We describe a unique ob- servation of leishmaniasis infiltration of the orbital apex.

Report of a Case. A 45-year-old man was hospitalized for evaluation of a right-sided headache of 4 weeks’ du- ration and 1 week of progressive graying of vision in his right eye . His Figure 1. Axial view of bone window computed tomographic scan with right sphenoid sinus opacity medical history was remarkable for extending through bone defect to the right orbit. Arrow demonstrates the infiltration into the right human immunodeficiency virus in- cavernous sinus. fection for approximately 14 years and recent diagnosis of AIDS due to signals on T2-weighted images pitalized for seizures and hemipa- the development of pulmonary Pneu- suggestive of fungal infection resis and died the next day. An au- mocystis carinii pneumonia and mul- (Figure 2). Hematoxylin-eosin topsy was not permitted. tidrug-resistant tuberculosis (CD4 staining of the specimen obtained by cell countϽ20/µL). endoscopic sphenoidectomy re- Comment. Leishmaniasis is caused Findings from neuro-ophthal- vealed intracellular organisms in the by an obligatory intracellular para- mologic examination revealed a vi- nasal and sphenoidal mucosa. Gi- site that is frequently transmitted sual acuity of 20/50-2 OD and 20/20 emsa stain also demonstrated the in- through the bite of infected sand flies OS. He could not see the control or tracellular organisms (Figure 3) from an animal reservoir. Other the test plates of the Ishihara color while the Gomori methenamine- modes of transmission including plates test with his right eye, but he silver stain was negative for organ- parenteral, congenital, and sexual saw all the plates with his left eye. isms. Gram stain did not show evi- have been reported. Mucosal leish- On tangent perimetry at1mhe dence of additional organisms. maniasis develops in less than 5% of could only count fingers in all quad- Fungal cultures of the biopsy speci- patients, typically months to years rants with his right eye, and with the men were also negative for organ- following localized cutaneous leish- left eye the field was normal to 2 mm isms. A diagnosis of leishmaniasis maniasis. Most cases of mucosal white object. In the right eye, there was made and confirmed by the Cen- leishmaniasis are associated with was 2 mm of exophthalmos with- ters for Disease Control and Preven- L braziliensis, commonly referred to out ptosis, swelling, conjunctival hy- tion and the species identified as as American leishmaniasis. The pro- peremia, or limitation of ocular mo- Leishmania braziliensis. cess often starts in the nasal sep- tility. The pupils were round and The patient was treated with in- tum and results in perforation. The reactive to light; the right pupil was travenous Pentostam (a European diagnosis is made by demonstra- less reactive with a relative afferent orphan drug; sodium stibaglu- tion of parasites by Giemsa stain on pupillary defect. Results of slit- conate) 1200 mg/d. Despite treat- biopsy specimens from affected tis- lamp biomicroscopy and ophthal- ment, the vision in his right eye de- sue. Newer methods include anti- moscopy were unremarkable. teriorated to no light perception, and gen detection, polymerase chain re- Computed tomography dem- right third, fourth, and sixth cra- action detection, and skin test. onstrated a sphenoid sinus lesion nial nerve palsies appeared. Addi- Mucosal leishmaniasis tends to be a that extended into the right orbital tional computed tomography re- chronic progressive disease that re- apex through an area of bone ero- vealed progression of the process at sponds poorly to the treatment. Pen- sion (Figure 1). Magnetic reso- the orbital apex. Simultaneously he tostam (20 mg/ kg) is used as first- nance imaging revealed diffuse developed a severe pneumonia line therapy for leishmaniasis and opacification of the sphenoid sinus caused by Aspergillus and 2 months amphotericin B (0.5-1 mg/kg) as sec- with areas of bright and decreased following the diagnosis he was hos- ond-line treatment.1-2 In patients

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©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 phoma should also be considered in the differential diagnosis of sinus disease in a patient infected with human immunodeficiency virus.6,7 We could not find another case of sinusitis and optic neuropathy due to leishmaniasis. This case should alert ophthalmologists to the possibility of unusual infectious agents as the cause of orbital apex disorder in patients with AIDS.

Ruth Huna-Baron, MD Tel Hashomer, Israel Floyd A. Warren, MD William Miller, MD Joseph Jacobs, MD Jeffrey Green, MD Mark J. Kupersmith, MD New York, NY

Corresponding author: Mark J. Ku- persmith, MD, Institute for Neurol- ogy and Neurosurgery, Beth Israel Medical Center, North Division, 170 East End Ave, New York, NY 10128 (e-mail: mkuper@ bethisraelny.org).

1. Evans TG. Leishmaniasis. Infect Dis Clin North Am. 1993;7:527-546. 2. Magill AJ. Epidemiology of the leishmaniasis. Dermatol Clin. 1995;13:505-523. 3. Chu FC, Rodrigues MM, Cogan DV, Neva FA. Figure 2. T2-weighted magnetic resonance imaging scan with a bright signal (arrow) of sinus mucosa Leishmaniasis affecting the eyelids. Arch Oph- and one area of decreased signal, extending to the right orbit. thalmol. 1983;101:84-91. 4. Chaudhry IA, Hylton C, DerMarchais B. Bilat- eral ptosis and lower eyelid ectropion secondary to cutaneous leishmaniasis. Arch Ophthal- mol. 1998;116:1244-1245. 5. Alvar J, Gutierrez- Sollar B, Molina R. et al. Preva- lence of leishmania infection among AIDS patients. Lancet. 1992;339:1427. 6. Meyer RD, Gaultier CR, Yamashita JT, et al. Fun- gal sinusitis in patient with AIDS: report of 4 cases and review of the literature. Medicine (Baltimore). 1994;73:69-78. 7. Pamilla PV, Morris AB, Joworek A. Sinonasal Non Hodgkin lymphoma in patients infected with human immunodeficiency virus: report of three cases and review. Clin Infect Dis. 1995;21:137- 149.

Sclerochoroidal Calcification With Choroidal Neovascularization

In 1991, an 80-year-old woman had Figure 3. Giemsa-stained tissue biopsy specimen demonstrating the intracellular Leishmania (arrows) (original magnificationϫ400). metamorphopsia and visual loss in the left eye. Visual acuity was 20/25 with AIDS, the compromised im- rience sinusitis, typically due to bac- OD and 20/30 OS. Visual fields plot- mune status contributes to the dis- teria, but sinus infections and orbital ted on a Goldmann perimeter semination of the infection and involvement have been described showed a large inferonasal sco- atypical presentation.5 with Aspergillus species, Pseudall- toma in both eyes. Fundoscopy re- Patients with the human immu- escheria boydii, microsporidia, and Al- vealed bilateral tumorlike, sclero- nodeficiency virus commonly expe- ternaria species. Non-Hodgkin lym- choroidal calcifications localized,

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©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 Figure 1. Fundus photographic views at initial examination show superotemporal sclerochoroidal calcifications in both eyes. Note a hemorrhage located centrally and a rim of hemorrhages located inferiorly of the calcifications at the border of a subretinal membrane in the left eye. No hemorrhages were observed in the right eye.

Figure 2. Left, Venous-phase fluorescein angiogram of the left eye at initial examination demonstrates a well-defined subretinal neovascular membrane. Right, Late-phase angiogram of the same eye shows diffuse leakage from the membrane and staining of the sclerochoroidal calcifications. Note also the linear and pinpoint early hyperfluorescent lesions on the surface of the calcifications and profound late hyperfluorescence of a focus superior to the central hemorrhage, as well as another focus temporal to the neovascular membrane at the inferior border of the calcifications.

with the largest part anterior to the tion of the retinal pigment epithe- observed. This scar enlarged dur- upper temporal arcades, and ex- lium, and with several hyperfluores- ing the 7-year follow-up period tended, with a smaller part poste- cent lesions suspicious for small (Figure 3, right). The sclerocho- rior to the arcades (Figure 1). These vascular tufts lying beneath the retina roidal calcifications and the 2 foci lesions corresponded with the vi- on the surface of the calcifications suspicious for subretinal neovascu- sual field defects. (Figure 2, left). In the late phases larization remained unchanged and In the left eye, we noted cho- of the fluorescein angiogram, we no new hemorrhages were noted. roidal neovascularization at the in- noted intense hyperfluorescence of In the right eye, we observed a ferior border of the sclerochoroidal the sclerochoroidal calcifications in similar aspect of the sclerochoroi- calcifications, hemorrhages surr- both eyes (Figure 2, right). Superior dal calcifications, with 1 more ob- rounding the membrane, and a single to the central hemorrhage and tem- vious lesion at the inferior border of hemorrhage centrally in the area of poral to the neovascular membrane the mass. This lesion was clinically the calcifications. The fluorescein an- at the inferior border of the sclero- atrophic but was associated with in- giography of the left eye showed hy- choroidal calcifications, we noted 2 tense hyperfluorescence and with re- pofluorescence of the sclerochoroi- well-demarcated zones of more pro- current hemorrhages (Figure 3, left). dal calcifications in the arterial phase. found depigmentation of the retinal The atrophic aspect of the lesion re- In the venous phase, a well-defined pigment epithelium. These areas mained unchanged and we never di- choroidal membrane was identified showed pronounced late hyperfluo- agnosed a choroidal neovascular that was 1 disc area large. More- rescence and were suspicious for foci membrane. However, we presume over, progressive irregular fluores- of subretinal neovascularization. Af- that a similar lesion has preceded the cence of the sclerochoroidal calcifi- ter laser photocoagulation of the neovascular growth in the left eye. cations was noted, with window well-defined choroidal membrane, Ultrasonography showed a mass defects in areas with depigmenta- formation of a flat atrophic scar was with 100% spikes and progressive at-

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©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 Figure 3. Fundus photographic views after 7 years show a hemorrhage at the inferior border of the sclerochoroidal calcifications in the right eye. A large atrophic laser scar is noted in the left eye. scan confirmed the presence of a large calcified mass in the posterior pole of both eyes (Figure 5). The sclerochoroidal calcifications remained nearly unchanged during the long follow-up period, with only a mild in- crease of the associated atrophic changes. A recent indocyanine green angiography was performed, with the aim to detect occult choroidal neovascularization at an early stage. The indocyanine green angiogram revealed patchy hypofluorescence in all phases in the areas with calcifications and atrophic changes. More- over, there was a faint late hyperfluorescence at the borders of the mass. No peculiar hyperfluorescence was noted of the lesion with recurrent hemorrhages in the right eye. Dur- ing the patient’s last examination, a G = 81.6dB bilateral cataract was noted, and visual acuity was 20/30 OU. Our patient had a multinodu- lar goiter and mild hyperthyroid- ism that were treated medically. Screening of calcium metabolism showed no disturbances and no ar- guments for primary hyperparathyroidism, but it was confirmed that the patient had secondary hyperparathyroidism caused by vitamin A deficiency, which is a common find- ing in elderly persons.

COMMENT

Sclerochoroidal calcifications are mm usually observed in the midperiph- eral fundus of elderly patients who Figure 4. Top, Ultrasonography shows a 100% spike and progressive attenuation of the spikes. Bottom, are asymptomatic. The lesions are B scan shows highly reflective calcification with acoustic shadowing. frequently bilateral and localized in tenuation of the spikes in both eyes flective calcification with acoustic the superotemporal quadrant.1-4 Two (Figure 4, top). On the B scan, the shadowing were seen (Figure 4, types of sclerochoroidal calcifica- characteristic findings of highly re- bottom). A computed tomographic tions are identified: relatively flat

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©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 expand close to the macular area, and the risk of visual loss because of associated choroidal neovascularization seems to be extremely low. On the other hand, the case of Cohen et al5 and our experience show that serous detachment and exuda- tive lesions may occur in the context of sclerochoroidal calcifications that 5 cm are complicated by choroidal neovascularization, and that laser treatment may be effective in reducing the risk of developing additional visual field loss. In 2 cases treated with lasers, no recurrence of the choroidal neovascularization was observed.

Figure 5. Axial computed tomographic section shows a large sclerochoroidal calcified mass in both eyes. Anita Leys, MD Peter Stalmans, MD plaque-like lesions and elevated tu- cifications with a well-defined sub- Johan Blanckaert, MD morlike lesions, ranging up to 6 mm retinal membrane and several foci Leuven, Belgium in height.3 with hemorrhages and hyperfluores- Recently, a first case of sclero- cence suspicious for choroidal neo- choroidal calcifications with cho- vascularization. During the 7-year fol- Corresponding author: Anita M. Leys, roidal neovascularization was re- low-up, these foci did not evolve to MD, PhD, University Hospitals Leu- ported.5 In this woman (aged 74 subretinal membranes and there was ven, Department of Ophthalmology, years), bilateral sclerochoroidal cal- no recurrence of choroidal neovas- Capucijnenvoer 33, 3000 Leuven, Bel- cifications were discovered during cularization from the well-defined gium (e-mail: [email protected] a routine examination. One plaque membrane after laser treatment. .ac.be).

of calcifications was associated with Several studies of series of pa- 1. Sivalingam A, Shields CL, Shields JA, et al. Id- lipid exudates and serous detach- tients with sclerochoroidal calcifica- iopathic sclerochoroidal calcification. Ophthal- ment. Fluorescein angiography was tions report an absence of choroidal mology. 1991;98:720-724. 2. Munier F, Zografos L, Schnyder P. Idiopathic indicative of ill-defined choroidal neovascularization. Thirty-four cases sclerochoroidal calcification: new observa- neovascularization. Argon laser pho- have been studied by Sivalingam et tions. Eur J Ophthalmol. 1991;1:167-172. tocoagulation induced regression of al,1 Munier et al,2 and Schachat et al3 3. Schachat AP, Robertson DM, Mieler WF, et al. Sclerochoroidal calcification. Arch Ophthalmol. serous detachment and exudates, and no choroidal neovasculariza- 1992;110:196-199. and there was no recurrence dur- tion was observed in their cases. With 4. McCabe CM, Mieler WF, Postel EA. Idiopathic sclerochoroidal calcification in a 41-year old ing a 2-year follow-up (S. Y. Co- fewer than 50 reported cases with- woman. Arch Ophthalmol. 1997;115:1082- hen, MD, personal communica- out choroidal neovascularization, the 1083. tion, December 14, 1998). incidence of this complication is 5. Cohen SY, Guyot-Sionnest M, Puech M. Cho- roidal neovascularization as a late complica- We report the second case in the probably extremely low. Moreover, tion of hyperparathyroidism. Am J Ophthalmol. world literature of sclerochoroidal cal- sclerochoroidal calcifications do not 1998;126:320-322.

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